Topics in Geriatric Rehabilitation
pp. 1–13
c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright Why Dance for Parkinson’s Disease
Olie Westheimer, MA
Brooklyn Parkinson Group (BPG) in collaboration with Mark Morris Dance Group (MMDG),
a renowned modern dance company, developed dance classes for persons with Parkinson’s
disease (PD), friends, and family. In 5 years, classes have increased from 2 to 9 participants once
a month, to weekly classes of 20 to over 30 participants. Professional dancers teach the classes in
a large dance studio with live piano accompaniment. This article explains the rationale of dance
for PD, describes teaching methods, and includes participants’ observations. Perceived benefits
noted by 15 participants with PD to a validated questionnaire are discussed. Key words: dance,
exercise, imagery, music, quality of life, Parkinson’s disease, socialization
B
ROOKLYN PARKINSON GROUP (BPG),
a chapter of National Parkinson Foundation (NPF), provides outreach services in affiliation with the Clinical Center of Excel-
lence for Parkinson’s Disease and Related Disorders, Kings County Hospital/SUNY Downstate Medical Center, Brooklyn, NY. The first
outreach service offered was a monthly support group meeting, which attracted 5 to 10
attendees, persons with Parkinson’s disease
(PD) and caregivers. Some were newly diagnosed, and others affected for 10 years and
more. Meetings combined discussion with
talks by invited speakers on topics such as
tips for clear speech, nonmotor deficits, and
confusion in PD. A personal review of what
had been learned after 1 year coalesced into
2 strong impressions. (1) At meetings, many
persons with PD and caregivers exhibited, but
did not talk about in a direct manner, the frustration, anger, and sadness that the diagnosis
of PD had created for both of them. Only 1
person with PD talked openly about being depressed. (2) The content of the daily lives of
persons with PD seemed to revolve mainly
around PD, with many doctors’ appointments,
PD support group meetings (many attended
several support groups), much time spent
reading about PD, and for some, appointments with a variety of therapists. Likewise,
many spouses’ and partners’ lives seemed to
have become mainly defined by being a caregiver. The conclusion drawn was that the support group attendees needed to do something
enjoyable, together—just plain fun, unrelated
to PD. The rationale section explains why
dance for PD was chosen.
From the Brooklyn Parkinson Group, a chapter of
National Parkinson Foundation, and Clinical Center
of Excellence for Parkinson’s Disease and Related
Disorders, Kings County Hospital/SUNY Downstate
Medical Center, Brooklyn, NY.
The author thanks the National Parkinson Foundation
for its support of the Brooklyn Parkinson Group dance
program and other outreach activities, and the NPF
Clinical Center of Excellence for support, hands on help
and advice. She and all dance class participants are
grateful to the Mark Morris Dance Group for its financial support of the Dance for PD classes.
“Dance for PD” classes are an evolving, collaborative
effort. “Dance for PD” classes are taught by Mark Morris Dance Group company members John Heginbotham
and David Leventhal, dancer, and Mark Morris Dance
Group School faculty member Misty Owens, and pianist William Wade. They work with Brooklyn Parkinson Group and class participants to refine, enrich,
and expand our Dance for PD repertoire. The classes
owe their existence to the encouragement of my husband, Ivan Bodis-Wollner, and to the interest of Nancy
Umanoff, Mark Morris Dance Group Executive Director, who was willing to take a chance and support
them. Eva Nichols, MMDG Education Director, works
with Brooklyn Parkinson Group to expand the “Dance
for PD” Program, and makes sure the classes happen
every week.
Corresponding author: Olie Westheimer, MA, Clinical
Center of Excellence for Parkinson’s Disease and Related Disorders, Kings County Hospital/SUNY Downstate Medical Center, Brooklyn, NY 11201 (e-mail:
[email protected]).
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WESTHEIMER
RATIONALE FOR DANCE FOR PD
1. Persons with PD, caregivers, and
friends could participate in dance
classes individually, each at his or her
own level, while at the same time, be
part of a group. Dancing with others
in a class is a highly social activity.
2. Dance classes would provide exercise, integral to health for persons
of all ages and advocated for persons with PD. Dance movement sequences stretch and strengthen muscles, increase flexibility in neck, shoulder, trunk, limb, fingers, hands, toes,
and feet, and contribute to aerobic
stamina. The way dance is taught promotes heightened awareness of where
all parts of the body are in space at
all times. How to maintain balance
is a fundamental skill developed in
dance. The benefits of exercise, however, are subsidiary aims of a dance
class. The primary goal is aesthetics—
specifically, moving with grace—just
for the sake of beauty, and also, often, for expressing feelings and telling
stories through movement. Dancing
would take mind and spirit away
from thoughts of disease and disability. Dance classes, therefore, would
improve the mood of persons with PD
and caregivers.
3. It is well known that visual cues1 and
musical rhythms2 often help persons
with PD who no longer can rely on
their unconscious sense of balance
and ability to initiate and control automatic movements such as walking.
What well-trained dancers know how
to do very, very well, is control their
movements with cognitive strategies
and conscious use of all sensory input. It was assumed that persons with
Parkinson’s disease as well as others
in the class would benefit from and
enjoy learning techniques dancers
use to stand, sit, and move with
grace.
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TOPICS IN GERIATRIC REHABILITATION
PARTICIPANTS
All persons with PD are welcome to join
the class and to bring a family member, friend,
or caregiver. In the first year the once a
month class size ranged from 2 to 9 persons.
A few times only 1 person showed up. In
the past 2 years the now weekly classes have
grown from 18 to 32 persons. The class consists of persons with PD who come on their
own, others who come with spouse, relative
or friend, and attendants. The classes always
have more persons with PD than others. Age
range of those with PD is 50 to 90 years, with
more men than women. Disability from PD
ranges from persons recently diagnosed, to
persons who use a walker or cane or are in a
wheelchair; exhibit tremor, freezing, retropulsion, kyphosis, tire easily, complain of memory problems, have difficulty getting out of a
chair and walking backward. Three persons
who come to classes have had deep brain
stimulation (DBS). On the Hoehn and Yahr
scale,3 symptoms exhibited would fall into
stages 1, 2, 3, and 4.
AMBIENCE AND TEACHING METHODS
OF DANCE FOR PD
Location
The 1-hour 15-minute weekly classes are
held in a large dance studio with wooden
floor, a ballet barre along 3 walls and floor to
ceiling mirrors on one wall. A piano is in one
corner. Next to the studio is a lounge with a
few large tables, chairs, and sofas where participants can leave their belongings, relax, and
talk before class begins. The entire building
is wheelchair accessible and bathrooms are
just across the hall from the dance studio and
lounge.
Personal contact and conversation
There is time before class for greetings and
small talk. The dance leaders say hello to
participants whom they have seen in previous classes. A representative of BPG acts as
host, greeting people and introducing new
WHY DANCE FOR PD
participants. In class, participants are addressed by name. Discussion is a part of the
dance classes.
The 3-part format of a traditional ballet
class---at the barre, in the center, moving
across the floor---is adapted
1. Warm-up, during which basic movements for the whole body, weight
shifting, and balance are practiced at
the barre with one hand touching
for proprioceptive feedback, is done
instead with participants seated and
also, for some sequences, holding the
back of their chair.
2. Practice of these same kinds of movements in the center of the room with
no tactile feedback is done instead
at the barre with one or both hands
touching.
3. Memorized,
choreographed
sequences performed across the floor
while the teacher observes, are done
instead with the teacher leading.
Live musical accompaniment
Just as in a traditional dance class or on
stage, the tempo and style of music played
affects the quality of movement dancers use,
continually informing them of how and when
and in what way they should move. “Pachelbel’s Canon,” for instance, elicits flowing adagio movements. It is often used in the beginning of class while everyone is seated, to
accompany some variation of a sequence for
upper body warm-up in which arms, back,
trunk and neck bend and curve, slowly in
all 4 directions—dance variations of the yoga
sun salutation. Another favorite piece is “Hernando’s Hideaway” from the musical “Pyjama
Game.” The well-known lyrics of the song
support the dramatic, story-telling sequences
the dancers create for this piece, while the
rhythm supports the sequence of movements
choreographed to fit the beat. In some classes,
participants pay particular attention to a variety of rhythms by listening to them played
on the piano or clapped by the accompanist,
then clapping them out. Participants derive
obvious pleasure from the well-known classical music, Broadway songs, and popular tunes
that are played. Sometimes we all just spontaneously sing along.
Internal imagery
Imagery is perhaps the most effective cognitive strategy dancers use to learn movement
sequences and to create particular effects
while dancing, although cognitive strategy is
probably not how dancers would label the
process of conjuring up in the “mind’s eye” a
representation of a movement effect they are
trying to achieve. Thus in the class, instructions very often point out the shape a movement makes in space; for instance, “curve
your arm around in front of you, continuing
down, up and over, completing a full circle in
the air.”The desired quality of movement for a
sequence is almost always explained through
imagery: “Vamp it up! Make eye contact with
someone across the circle from you and move
your upper body seductively.” “Lower your
arms softly, as though they are floating down
on top of gentle wafts of air.” “To help yourself stand tall, imagine you are a puppet and a
string is pulling your head, neck and torso up
to the ceiling.” No matter what kind of movement is involved, or even when standing still,
in dance, the effect of the whole body is important, not just one part. Imagery evoked,
therefore, tends to create a picture (representation) of how the whole body should move
together.
Aural and visual inputs
As noted, participants hear the rhythm of
the accompanying music and respond to the
musical effect and also to the beat. Teachers
usually also call out what movement to do
in sequence, and at the same time they are
dancing too, so that participants have 2 aural
guides and a visual guide.
Tactile input
While in the center of the room, participants often perform sequences holding
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WESTHEIMER
hands, in a circle or line, adding touch or somatosensory input to aural and visual inputs.
Dancers rely on light touch to focus attention
on balance. That’s why in the beginning of a
ballet class, students lightly touch the barre,
and it is one of the reasons why in a pas de
deux ballerinas make light contact with their
partners’ fingers when executing a sequence
that requires extreme concentration on
balance.
Both dancers and neuroscientists know
that touch synchronizes (entrains) movement.
In 19th century, romantic ballets members
of the corps often hold hands or clasp at
the waist while dancing. Such connections
create a beautiful pattern, but they also enhance synchrony of movement. In “Rhythms
of the Brain,” neuroscientist Gyorgy Buzsaki
describes oscillatory synchrony with the example of romantic couples holding hands,
which results in their walking in perfect unison, and notes that this will not happen if a
couple does not hold hands.4(p168) This phenomenon occurs in Dance for PD classes too,
for example, when participants join hands in
a circle and perform a walking pattern. Synchrony ensues.
Repetition, variations on familiar
sequences, and new sequences
Repetition: As in a traditional dance class,
constituent parts of movement sequences
and dance steps are practiced over and
over again. A basic tap step called the
perrididdle, for instance, consists of 4
parts continually repeated in the same sequence on one foot and then the other,
repeat, repeat, repeat: (1) strike the heel
(“dig”) of one foot while standing on the
other; (2) spank the floor with the ball of
that foot and lift it up; (3) step down again
on the ball of the same foot; and (4) drop
the heel of that foot to the floor. Then
shift weight and do the same thing with
the other foot. In the class, the parts of
the perrididdle and the whole perrididdle
are done while seated as part of warm-up
for the feet. A perrididdle tap routine is
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TOPICS IN GERIATRIC REHABILITATION
done again while holding on to the barre
with both hands, many, many times. Likewise port de bras arm curves and upper
body stretches may be used during seated
warm-up exercises, as upper body accompaniment to plies done at the barre and in
choreographed pieces in the center.
Variation: The dance leaders vary familiar
sequences, changing speed, quality of
movement, parts of the sequence, etc. In
one familiar sequence for instance, the
forearm is moved from a bent elbow close
to the body out to horizontal position in
front. The dance leader asks participants
alternatively to “make it sharp,” “make
it smooth.” (Accompanying music is also
alternatively sharp or smooth, as is the
dance leader’s voice in calling out the
movement.) These kinds of movement
quality variations focus mental attention
on movement control.
New sequences: Entirely new sequences are
taught. New sequences present a mental and physical challenge, and they are
learned over time with practice. It is
hoped that exposure in class to the strategies and sensory input dancers use to control movement will assist participants in
learning and executing new movements.
Low key, supportive instruction
Participants are often reminded that starting a sequence with the left arm or right
arm or leg will work, and not to worry, sequences take time to grasp mentally and to
execute. Participants may be helped individually to adapt a sequence to fit movements
they are able to do. Teachers encourage for
instance, good posture, stretching, lifting the
foot, but do not individually correct participants’ efforts.
Teaching of choreographed dance
sequences.
Teachers lead the class in performance of
an expanding repertoire of dance sequences,
for instance, jazz-based Broadway chorus line
WHY DANCE FOR PD
style numbers, dancing the gang rumble
scene from “West Side Story” (perhaps the favorite), simplified segments of dances choreographed by Mark Morris for MMDG, square
dances, pantomime stories.
Performance of free form dance
sequences created by groups of
participants
Grouped in pairs or groups of 3, either
seated or standing, in each group 1 or 2 persons follow the moves (mirror) the designated choreographer who moves in response
to the music in whatever way he or she
chooses. Sometimes the pianist changes the
tempo and musical style, which then affects
the choreographers’ moves. Each person in a
group has time to be the choreographer. The
dance leader may make suggestions that expand choreographic effects. (“Followers, see
if you can watch the choreographer and then
copy the movements trailing behind just a little.” “Let’s try responding to one another’s
moves. One person in each group, create a
sequence and then stop so that your partner
can respond to your moves with a sequence—
like a conversation in movement.”). The resulting duets and trios display a wide variation
in styles and beauty and are wonderfully synchronous. In one class, groups were asked to
dance playing a sport they liked for the rest
of the class. Choreographing together in small
groups requires mental and physical concentration on movement, self-reliance, cooperation, and gives participants a chance to get to
know one another.
Taking advantage of spontaneity
One day a participant with PD who came in
10 minutes late glided across the room to get
to an empty chair on the far side, swinging her
hips and smiling. The pianist started to accompany her. Everyone clapped, and the teacher
immediately suggested everyone stand up and
dance across the room to another chair, dancing together with others along the way if they
feel like it, which we all did. In another class,
a participant in a motorized wheelchair, ev-
idently stimulated by the music, decided to
move to the middle of the circle where the
teacher immediately joined him for a duet
which pleased everyone. We have learned
that participants are reluctant to agree if asked
to dance solo, but sometimes an opportunity
for spontaneous dance occurs and the dance
leaders take advantage when it does.
DANCE FOR PD CLASSES:
DEVELOPMENT OF CONTENT
BPG and MMDG collaborate
The dancers and I offer feedback and
suggestions via e-mail to provide a record
of thoughts and ideas about the classes. It
is sometimes hard while teaching, for the
dancers to gauge participants’ performance.
An e-mail note that some participants take
longer to learn sequences than others has
led to more time spent breaking down each
sequence into movement parts for practice
several times before practicing the total sequence, and repeating it with music 3 or more
times.
The dancers translate suggestions into
dance sequences. Three examples are as follows:
1. Because one side of the body in
PD is often less responsive than the
other, I requested a sequence to promote paying attention to movement
on both sides of the body. Dancers
responded with a variety of opposition sequences; for example, while
seated, one arm starts up in the air,
the other hangs down by the foot.
Each hand consecutively moves to
touch shoulder/knee, knee/shoulder,
and ends with the opposite arm up
in the air and down by the foot, a
sequence that requires practice and
attention to master for dancers as
well as persons with PD. Such a sequence evokes discussion because it is
hard to do. Dancers and participants
talk about what works for them, for
example, fingers touching the body
in transit from one stop to the next
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WESTHEIMER
(somatosensory input), copying the
teacher’s movements (visual input),
“just doing it and not thinking” (both
dancers and muscle physiologists call
this muscle memory), “thinking about
what the sequence looks like” (imagery), “lots of practice.”
2. A request for moving across the floor
using methods dancers use to travel
across a stage, as a way to get participants to think about and use eyes,
head, arms, legs, and feet while they
walk, has resulted in spending 10 to
20 minutes in many classes for jazzy
walks snapping fingers in sync with
the music, doing the grapevine holding hands, marching with high steps,
exaggerating each step as a lunge accompanied by an exaggerated arm
swing upward in the front to horizontal level with the floor.
3. A request for a sequence incorporating ways to stand up from a seated
position and sit back down again
became a sit-to -stand, stand-to -sit
circle dance, each person standing
up, walking to the next chair (sometimes around his or her own chair)
and sitting down again. Dance leaders demonstrate how dancers use momentum and the head, which is heavy,
to generate energy to get up from a
seated position. If persons have a hard
time getting up and sitting down on
their own, but want to try, they are
helped, usually by someone next to
that person, not necessarily the caregiver, friend, or attendant. If a person
feels tired or does not want to try he
or she does not participate. Usually
most people participate, completing
the full circle by sitting, standing and
walking from chair to chair.
Classes are interactive: Dance leaders
and participants collaborate
A comment from one participant about
painful stiffness in the neck and shoulders led
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TOPICS IN GERIATRIC REHABILITATION
to more ballet port de bras sequences during warm-up; slowly gliding curved arms over
the head, sideways, behind the back, below
the knees (while seated), with accompanying head and neck curves. A complaint about
dizziness led to a discussion of how dancers
learn where to focus the eyes to counteract
dizziness, and to direct movement. Dancers
often include where to look as part of instruction. Positive feedback from teaching a tap
step and Bob Fosse style isolated body part
jazz moves, has led to learning, practicing,
and performing bits of tap and jazz sequences.
During the class, participants are encouraged
to ask questions. In their comments participants sometimes mention PD and talk about
its effects. The dance teachers do not relate
their instruction to PD and do not mention
PD.
RESULTS
Quality of Life Scale
In March 2006, after the classes had been
held once a week for 17 months, BPG wanted
to find out what in particular about the classes
is most appreciated, as a source for development of a questionnaire more specifically
targeted to perceived effects of “Dance for
PD.” Participants were asked to complete the
16-item Oregon Health & Sciences University
version of the Quality of Life Scale (QOLS)
(Appendix 1). This scale is validated for persons with chronic diseases. It was used because its aim is to measure overall estimate
of quality of life, beyond issues only related
to health, and it is short. On a scale from
1 (Terrible) to 7 (Delighted), respondents
are asked to describe how satisfied they are
in 3 domains: (1) health, (2) relationships
and material well-being, (3) personal, social,
and community activity. BPG added a 17th
item, “Moving around: walking, standing up,”
which would fit into the domain of movement disorders. After marking how satisfied
they are on the 17 items, respondents were
asked to note whether they felt any of the
items had changed for the better as a result
of attending “Dance for PD” classes, and if so,
WHY DANCE FOR PD
Table 1. Self-assesment of dance class participants with PD to Quality of Life Scale
Items
Active recreation (15)
Socializing (13)
Feeling fit (2)
Understanding
yourself (10)
Learning (9)
Expressing yourself
(12)
Participating in
organizations (8)
Helping others (7)
Reading, music,
entertainment (14)
Moving around (17)
Independence (16)
Family relationships
(3)
Work (11)
Close friends (6)
Close relationships
with spouse (5)
3:
5:
1:
2:
Mostly
4:
Mostly
6:
7:
Terrible Unhappy Dissatisfied Mixed Satisfied Pleased Delighted
2
1
4
3
3
1
3
2
3
5
1
4
1
2
2
1
2
3
2
1
1
1
2
1
2
3
5
6
1
1
1
1
1
2
4
2
2
1
1
1
1
3
3
4
3
2
5
1
1
3
1
2
3
4
4
3
4
5
2
1
2
1
2
5
4
2
3
4
3
3
4
2
1
2
1
∗ Responses to Oregon Health and Science University version of the Quality of Life Scale (QOLS). Above are ratings for
each QOL item by the 12 persons with PD who also noted after filling out this QOLS, which items had ”changed for the
better” as a result of attending “Dance for PD” classes. Items are listed in order from highest number of improvement
responses to lowest. In this table, the numerical scores 1 to 7 reflect patients’ self-assessment of their condition. They
do not reflect self-assessment of improvement. Number in each of the cells indicates the total number of responses
received. Item 1(material comforts) and item 4 (rearing children) are not included in the table because, as would be
expected, none of the responders noted these items had improved because of attending “Dance for PD” classes. Item
17 (moving around) was added to the QOLS.
which ones. Table 1 shows the number of responses each item number received. Respondents were also asked to give their age, sex,
year of diagnosis with PD, and if they come to
class as often as possible.
Twenty-one responses were returned; of
these, 15 were from persons with PD. UPDRS
scores were not factored in. From observation
of persons who happened to be in class the
day QOLS questionnaires were handed out,
the respondents were in stages 1 to 4. Age
range of respondents was 50 to 87, with 2
in their 50s, 4 in their 60s, 6 in their 70s, 2
in their 80s, and one who did not note age.
Length of diagnosis of PD ranged from 1 to 10
years. Of respondents with PD 7 were male
and 8 female. All 21 respondents noted they
come to class “as often as possible.”
The 3 items that received the highest number of responses (8) that they had “changed
for the better as a result of attending Dance
for PD classes” were item 15, “Participating
in active recreation,” item 13, “Socializing—
meeting other people, doing things, parties,
etc,” and 2, “Health—being physically fit and
vigorous.” There were no negative responses
“changed for the worse” as a result of attending Dance for PD classes.
The 2 items that received the second highest number of responses (7) were
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WESTHEIMER
Item 10: “Understanding yourself—knowing
your assets and limitations—knowing
what life is about. . .” and item 9,
“Learning—attending school, improving understanding, getting additional
knowledge.”
Item 12: “Expressing yourself creatively,” received 5 responses.
Item 8: “Participating in organizations. . .” received 4 responses.
Three items (7, 14, and 17) received 3 responses each, Helping and encouraging others. . .,” “Reading, listening to music or observing entertainment,” “Moving
around: walking, standing up,” (added by
BPG).
Item 16: “doing for yourself,”and item 3, Relationships with parents, siblings,”received
2 responses, and 1 response each was
received by items 11, 6, and 5, “Work,”
“Close friends and “Close relationships
with spouse. . ..” No one responded that
item 1, “Material comforts” and 2, “Having . . . children” were improved through
dance classes.
Responses to questions asked by Misty
Owens, one of the dance leaders, for her
master’s thesis in dance on the ‘‘Dance
for PD’’ Program
At the same class at which the QOLS was
handed out, Misty Owens, one of the dancers
who lead the class, asked 5 persons who have
PD to respond via e-mail to questions about
the effect of the classes on them, as part of
her thesis on the “Dance for PD” program for
her MFA in dance from the University of Wisconsin at Milwaukee. Persons who responded
are 3 women F., aged 64, diagnosed for 10
years; L., aged 50, diagnosed for 6 years, and
M., aged 51, diagnosed 1 year; and 2 men, C.,
aged 64, diagnosed 10 years, and B., 71 diagnosed 6 years.
Key words taken from the 5 responses to
4 of the questions Misty asked appear below.
These questions are not validated, but they
ask specifically about the effects the dance
classes have on persons with PD. Complete
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TOPICS IN GERIATRIC REHABILITATION
text of the respondents to these questions is
given in Appendix 2.
Key words
1. “How does your body feel after
our dance class ends? Please describe.”Key words: much better, light,
floaty, graceful, relaxed, invigorated,
high energy, exhilarated, more flexible, symptom-free.”
2. “How do you feel in your mind after
the dance class ends?”Key words: run
and leap, smiling, courageous, sorry
it’s over, much happier, a little spacey,
good mood, focused and clear.”
3. “Do you feel the consequences of
the class impact your quality of life
on a daily basis? How?” Key words:
“fulfilling, empowering, optimistic, inspired, flexible, confidant.”
4. “What do you believe specifically
makes this dance class work for
you? What brings you back to class
each week? Please describe.” Key
words: “promotes possibilities, interactions, participation, learning, feeling symptom free, hope, joy, being fluid and graceful, comfortable,
anxiety-free, cheerful, enjoying the
movements, connections with others,
feeling great.”
DISCUSSION
Dance for PD classes were developed in response to a perceived need for persons who
attend BPG support group meetings to participate together in a community-based social activity, as equals, as just persons, rather than as
patients with PD or as caregiver. A shared activity open to everyone in the support group
would, it was thought, help with sadness, frustration, and preoccupation with PD, thereby
improving mood. Dance was chosen because
the exhilarating mental and physical effects of
dance were well known from personal experience and because of what was seen as a potential benefit to persons with PD from learning
WHY DANCE FOR PD
Figure 1. It shows the number of responses (vertical axis) in each of the 16 item self-rating QOL scale,
and to item 17, “moving around, walking, standing up,” added by BPG. Numerical scores of 1 (terrible) to
7 (delighted) represent patients’ assessments of condition, not degree of improvement. After completing
the QOL questionnaire, BPG asked respondents to note which of the 17 items had improved as a result of
coming to the dance classes. Fifteen persons with PD completed the QOLS of whom three did not note
whether or not there had been improvement. This figure shows that about half of all respondents felt most
improvement in “Participating in active recreation”(#15), “Socializing-meeting other people, doing things,
parties, etc” (#13), and “Health—being physically fit and vigorous” (#2), with “Understanding yourself”
(#10), and “Learning” (#9) slightly behind. “Expressing yourself” (#12) received 5 responses and “Participating in organizations” (#8) received 4. All other items 3 to 1 response, with zero responses to “Material
comforts” (#1), and “having/rearing children (#4). See Appendix 2 for the complete QOL. Responses received will be used to develop a new QOL questionnaire that is more targeted to eliciting responses to the
areas of life participants feel improve through dance.
about and practicing in the same way dancers
do, the conscious, attentive use of imagery,
and all sensory inputs to learn and control
movement.
We used the QOLS to determine what effects of the Dance for PD classes are most
appreciated by participants. The scale does
not address the potential usefulness of learning methods dancers use to control movement. Item 9 does ask responders to rate
“Learning . . . improving understanding, getting additional knowledge,” which received 7
responses, but it is unclear whether responders were thinking about the kind of heightened mental concentration on movement that
is taught in a dance class. In the open-ended
questions, only one person commented on
this aspect of the classes (question 1) that
they “inspired me to . . . monitor my motion.”
In the class, persons with PD do comment
for instance, that “I didn’t know I could do
so much,” and caregivers comment that they
are quite surprised at how much the persons
with PD are able to do. It is known that music
is able to help persons with PD synchronize
their walking rhythm to a musical beat2 and
this does indeed happen in class. Whether retention of learned movement sequences is improved via practice is not known. It is hoped
that through further research it will be possible to learn more about whether persons
with PD can benefit from learning methods
dancers use for movement control.
Responses as to which items on the QOLS
had improved as a result of coming to “Dance
for PD” classes (Fig 1 and Table 1) can be
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WESTHEIMER
viewed as confirmation that dance does make
participants feel better, and feeling better is
associated with improved mood. As was assumed, the items that responders noted most
often had improved as a result of the dance
classes were recreation (item 15, “Participating in active recreation”), being with other
persons (item 13, “Socializing”), and feeling
better physically (item 2, “. . . being physically fit and vigorous”). The opportunity for
socializing before class starts and also during class when working together in groups is
what most probably contributes to this finding. Personal contact and conversation make
the dance classes more meaningful and cohesive because participants have a chance to get
to know one another.
Perhaps the high number of responses to
item 2, feeling better physically, could be
seen largely as the result of the combination,
physical exercise, and heightened mental activity. It is interesting to note that 4 persons
rated themselves for “feeling fit” as “pleased”
and “mostly satisfied,” while 8 responses to
item 2 assessed feeling fit as “mixed” (4 responses) and “unhappy” (one response) yet 8
persons said there had been improvement in
feeling fit as a result of dance.
Music and imagery, we believe, play a role
here. They are 2 essential aspects of a dance
class, and they are intimately linked. Dancers
respond to the images that music evokes, and
in turn make conscious, active use of these
images to affect the quality of their movements. A study of the effect on persons with
PD of music therapy (MT) lends some support
to this possibility. Music therapy makes use
of both music and imagery in an alternative
medicine model of care, to improve emotional
state and motor control in all kinds of patients.
A study of the use of active MT in PD showed
that MT had a positive effect on motor abilities and emotional status and led to improvement in activities of daily living and quality of
life.5 It is interesting that item 17 added to the
QOLS, “moving around, walking, standing up”
received far fewer responses than item 2. If
the lower rating of item 17 were duplicated in
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TOPICS IN GERIATRIC REHABILITATION
a much larger study of the effect of Dance for
PD on quality of life, it might suggest that improvement in mood results more from feeling
better physically which is connected to mood
than from self-evaluation of actual improved
ability to move.
Although only 5 persons with PD were
asked to comment directly on the effect of the
dance for PD classes, and these questions have
not been validated, their responses (“lots of
feeling happy,” “floaty, even graceful,” exhilarated,” “invigorated,” “definitely good mood,”
“more courageous,” “empowering,” “fabulous
fun,”“more optimistic,”“more confident,”etc)
are a better reflection of the very positive
mood enhancing response that participants
have to these classes (Appendix 2) than responses to the validated QOLS.
Exercise is now recognized by the American Academy of Neurology as an alternative
therapy for PD that “may be helpful in improving motor function,”6 but its report notes
that the “magnitude of the observed benefit was small,” and “not sustained after exercise therapy was discontinued.”All 21 respondents to the QOLS said that they attend classes
as often as possible. “Dance for PD” classes
have the potential to motivate persons with
PD to make physical exercise a part of their
lives. It is known that for older adults regular exercise improves physical functioning
and emotional well-being, but getting older
adults to exercise, particularly those who are
disabled, is difficult. Less than a third exercise
regularly.7
Even if future research on the effect of
Dance for PD classes shows that the magnitude of physical improvement is small as the
American Academy of Neurology found is true
for exercise therapy, they could contribute to
overall quality of life of persons with PD and
caregivers. Dance is not only a physical activity but also a social activity and an absorbing
mental activity that engages emotions and the
imagination. In addition, the correspondence
is striking between how dancers use mind
and stimuli to control movement and how
mind and stimuli have already been shown to
WHY DANCE FOR PD
help persons with PD. More widespread implementation of “Dance for PD” classes and
validation are needed.
Please Note: Because of considerable interest in the “Dance for PD” classes, BPG and
MMDG have created a video about our classes
and organized a workshop that we hope will
be beneficial for dancers and persons in the
PD community who would like to develop
their own Dance for PD classes. For more
information, please contact BPG. [email protected].
REFERENCES
1. Lewis GN, Byblow WD, Walt SE. Stride length regulation in Parkinson’s disease: the use of extrinsic cues.
Brain. 123;10:2077–2090.
2. Thaut M, McIntosh KW, McIntrosh GC, Hoemberg V. Auditory rhythmicity enhances movement and speech motor control in patients with
Parkinson’s disease. Funct Neurol. 2001;16:163–
172.
3. Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. Neurology. 1967;17:427–442.
4. Buzsaki G. Rhythms of the Brain. New York: Oxford
University Press; 2006.
5. Pacchetti C, Mancini F, Aglieri R, Fundaro C, Mar-
tignoni D, Nappi G. Active music therapy in Parkinson’s disease: an integrative method for motor
and emotional rehabilitation. Psychosom Med.
2000;62:386–393.
6. Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner WJ. Practice parameter: neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review). Am Acad
Neurol. 2006;976–982.
7. Prohaska T, Rimmer J. Promoting Exercise in Older
Minority Adults and Those With Disabilities. Vol 3.
Roybal Issue Brief. Chicago, Ill: Midwest Roybal Center for Health Maintenance; 2001;1–7.
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WESTHEIMER
Appendix 1
Quality of Life Scale∗
Please read each item and circle the number that best describes how satisfied you are at
this time. Please answer each item even if you do not currently participate in an activity or
have a relationship. You can be satisfied or dissatisfied with not doing the activity or having the
relationship.
(Note: Participants were asked to rate their feelings on a scale of 1 to 7: Terrible, Unhappy,
Mostly Dissatisfied, Mixed, Mostly Satisfied, Pleased, or Delighted).
1. Material comforts—home, food, conveniences, financial security.
2. Health—being physically fit and vigorous.
3. Relationships with parents, siblings & other relatives—communicating, visiting, helping.
4. Having and rearing children.
5. Close relationships with spouse or significant other.
6. Close friends.
7. Helping and encouraging others, volunteering, giving advice.
8. Participating in organizations and public affairs.
9. Learning—attending school, improving understanding, getting additional knowledge.
10. Understanding yourself—knowing your assets and limitations—knowing what life is
about.
11. Work—job or in home.
12. Expressing yourself creatively.
13. Socializing—meeting other people, doing things, parties, etc.
14. Reading, listening to music, or observing entertainment.
15. Participating in active recreation.
16. Independence, doing for yourself.
17. Moving around—walking, standing up (17 was added by BPG)
After completing the QOLS, respondents were asked by BPG:
“Have any of the numbered items, 1 to 17, changed for the better as a result of attending the
Dance for PD classes? If so, please write the numbers below.”
∗Adapted by Oregon Health & Science University for groups with chronic illness.
Appendix 2
E-mailed Responses on Effect of Dance Classes Received From 5 Participants With
Parkinson’s Disease
The responses below are to questions concerning the effect of the classes, asked via e-mail
by dance leader Misty Owens, for her MA thesis on the “Dance for PD” Program. Responses are
from 5 of the participants who also answered the QOLS. Age, sex, and length of diagnosis of PD
are as follows: F. 64, female, 10 years; C. 64, male, 10 years; M. 61, female, 1 year; L. 50, female,
7 years; B. 72, male, 5 years.
1: How does your body feel after our dance class ends? Please describe.
F: Much better, particularly in my arms. Even though I take exercise classes 2 times a week
besides our class, our class has a much bigger impact on the way may arms feel as a result of
the way we use them (pushing up and around and back and forth). Also I feel much happier
after the class than I do in most places. It’s such a joy having William’s wonderful music, your
wonderful dance, (and John, David and other dancers) and lots of feeling happy.
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TOPICS IN GERIATRIC REHABILITATION
WHY DANCE FOR PD
C: The duration of my period of normalcy varies. It always lasts until after the end of the dance
class. However, at some point PD symptoms return. Sometimes on the way home. Sometimes
thereafter. I do not often notice when or where the return occurs.
M: Light, floaty, even graceful. High energy. Snapping my fingers, singing, etc.
L: I usually feel energized, exhilarated and symptom-free. Looser, I think.
B: “I am relaxed, invigorated and more flexible.”
2. How do you feel in your mind after the dance class ends?
F: . . . As though I could run and leap . . . and enjoy smiling and talking to the others. . .
C: Always sorry that class is at an end. And I feel “normal” i.e., symptom-free for a while.
M: A little spacey, a little high, definitely good mood, filled with music.
L: Focused and clear.
B: A little fatigued and much more courageous about walking. I feel good about myself, I’m
at ease.
3. Do you feel the consequences of the class impact your quality of life on a daily basis? How?
F: It provides a feeling that . . . my future life incorporates opportunities that will be fulfilling,
and therefore empowering.
C: A very positive effect. At other times . . . I may not feel as free of PD symptoms . . .. But
because I am symptom-free during class, I know that I can be . . . that knowledge has an ongoing
positive effect on my attitude.
M: Well for one thing it’s fabulous fun—like stepping into a totally loving kind and beautiful
universe. Inspired me to buy CDs, to keep music in my daily life. And to monitor my motion.
L: I feel more optimistic about my PD and being able to do well for a long time and inspired
by all the others who are doing so well . . .
B: I believe I am more flexible and more confident in my ability to walk.
4. What brings you back to class each week?
F: . . . interactions with all of us, ways of helping each other, getting to know each other,
learning together, promotes possibilities rather than a lack luster future . . ..
C: . . .positive feeling that I derive from the magical ability of the dance classes to free me
from posture and gait problems temporarily . . . hope that the experience instills in me . . . joy of
the experience . . . performing movements relatively free of embarrassment and inhibition . . .
the comfortable, anxiety-free company of this group who do not assume . . . that a person with
PD may not be able to do whatever is called for.
M: Welcoming part of it. . .. William and the music . . . the dancing, the Mark Morris-y bits we
get to do. I floated on Dido & Aeneas (Mark Morris choreography) . . . the variety . . . I like it
when we go over a routine enough so I can do it without watching. . ..
L: . . . it’s the mixture of knowing this is good for my body . . . I enjoy the actual movements,
the LIVE music . . . (an essential ingredient!) . . . connection with so many others with PD . . .
and I feel really great after class ends.
B: The teachers, the group of participants who are very kind and accepting and the results
of what it does for me.
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